PROTOCOL: Effectiveness of home-based interventions to prevent child neglect: A systematic review

Description of the condition

Neglect, which is the most common type of child maltreatment, is most frequently associated with child fatality (HHS, 2022). According to the World Health Organization (WHO) global status report on preventing violence against children 2020 and responding to child maltreatment: a clinical handbook for health professionals, 16% of children have been neglected (WHO, 2022). Median rates of neglect were highest in Africa (girls 42%, boys 39%) and South America (girls 55%, boys 57%). By contrast, median rates of neglect differed between the sexes in North America (girls 41%, boys 17%) but were similar in Asia (girls 26%, boys 24%) (WHO, 2020). Additionally, in the United States, according to the U.S. Department of Health & Human Services Child Maltreatment 2021 (HHS, 2023), there are 600,000 victims of maltreatment in 2021, and three-quarters (76.0%) of victims are categorized as neglect. A nationally estimated 1820 children died as a result of abuse and neglect, with 77.7% suffering neglect. The Consultation on Child Abuse Prevention has defined child neglect as “In the context of resources reasonably available, family or caretaker's failure to provide for the development of the child in all spheres, including health, education, emotional development, nutrition, shelter, and safe living conditions, and cause or have a high probability of causing harm to the child's health or physical, mental, spiritual, moral or social development” (WHO, 1999). In general, child neglect is a heterogeneous construct encompassing rather dissimilar negative child experiences, and the several basic categories of child neglect include educational neglect, emotional neglect, inadequate supervision, medical neglect, and physical neglect (Child Welfare Information Gateway, 2018).

Multiple risk factors of child neglect have been identified, of which family-related factors are the most prominent. These factors include having a history of antisocial behavior/criminal offenses, having a history of mental/psychiatric problems, having a history of mental or physical problems, and having a low educational level among parents (Mulder, 2018). The mental, physical, and/or behavioral problems of children were also found to increase the risk of child neglect. Meanwhile, various studies have shown a range of possible adverse consequences of child neglect. Specifically, research indicates that child neglect might lead to an additional 3-month syntactic delay, subsequently impacting cognitive function (Kobulsky, 2022; Naughton, 2013; Spratt, 2012). Across various studies, children subjected to neglect face a significantly higher risk (two to three times) for depressive, anxiety, eating, and behavioral/conduct disorders, with a notable dose–response relationship for depressive disorders (Norman, 2012). Furthermore, correlation analysis research suggests that child neglect is associated with diminished task involvement, lower creativity, and difficulty discerning emotional expressions in peers. Additionally, it is linked to lower overall intelligence and self-esteem scores (Kobulsky, 2022; Naughton, 2013). Moreover, children subjected to neglect experience increased disciplinary problems, suspensions, grade retention, and special educational needs, accompanied by deficits in emotional knowledge (Maguire, 2015). The health consequences of child neglect extend to changes in brain maturation, dental caries, injuries, and, in severe cases, death (Avdibegović, 2020; Brandon, 2014; Fisher-Owens, 2017).

While it remains important to quantify and understand the physical and behavioral health impacts of child abuse and neglect, adequate literature has established foundational justification to support prevention efforts (Ogle, 2022; Welch, 2013). For example, certain epidemiological studies on the association of adverse childhood experiences (ACE) with physical health have demonstrated a lower impact of neglected early ACEs versus chronic ACEs, emphasizing the potential of meaningful intervention to reduce the risk trajectory (Chaiyachati, 2021; Thompson, 2015). The prevention of child abuse and neglect has become a public health priority, given its now well documented impact on the health and wellbeing of a developing child (Berger, 2015; Centers for Disease Control [CDC], 2016; Guterman, 2013). Over the past few decades, the evidence base that supports preventive interventions has increased significantly, with promising findings emerging from various preventive strategies, particularly home-based interventions (Ash, 2017; Guastaferro, 2022). The United Nations International Children's Emergency Fund (UNICEF) supplemented in-person group and home-based programs with innovative remote and digital delivery modalities to enhance prevention of violence, exploitation, abuse, and neglect (UNICEF, 2023). The CDC developed a technical package for preventing child abuse and neglect. The package includes the following five strategies for prevention: strengthen economics, change social norms to support parents and positive parenting, provide quality care and education, enhance parenting skills to promote healthy child development, and intervene to lessen harms and prevent future risk; home visiting programs is one of the key ways to implement these strategies (CDC, 2016). The 2018 Family First Prevention Services Act requires the states in the US to develop, operate, expand, and enhance community-based, prevention-focused programs and activities designed to strengthen and support families to prevent child abuse and neglect (HHS, 2018). In 2018, the US Preventive Services Task Force (USPSTF) performed an evidence review of primary care interventions to prevent child maltreatment and found that the most common research included in the evidence review was the studies on home visitation-based interventions (Curry, 2018).

Description of the intervention

In general, the goals of home-based intervention include providing parents with information, emotional support, access to other services, and direct instruction on parenting practices (although programs vary in how they achieve these goals as well as in the relative importance placed on the goals) (Dongmo, 2021; Howard, 2009; Pamungkas, 2019; Welsh, 2011; Williams, 1995).

Home-based intervention is an increasingly popular method for delivering services to families. In particular, for high-risk families with infants and young children, providing services within the context of the family's home appears a useful and effective strategy in preventing or reducing the incidence of childhood diseases (Berger, 2015; Curry, 2018; Dongmo, 2021; Haines, 2018; Mirotta, 2018; Pamungkas, 2019; Taverno, 2017). Many different programs or models of home-based interventions exist to prevent or reduce the incidence of child neglect. For example, The Australian Institute of Family Studies performed comparative analysis using 10 different home visiting programs for preventing child abuse or neglect. These programs aimed to improve parenting competence and enhance child development. Moreover, they provided parents with education regarding child development and parenting techniques as well as practical assistance such as linking families to services and social supports (Australian Institute of Family Studies, 2006). The 2021 Home Visiting Evidence of Effectiveness (HomVEE) assessed 65 early childhood home visiting models, of which 24 met the HHS criteria to prevent or reduce the incidence of child abuse and neglect (HHS, 2021).

For the present study, we are interested in formal home-based intervention (Li, 2022; Van, 2020), and it is defined as receiving help from professional or paid workers rather than informal caregivers (i.e., most commonly family members and friends) in the home. Home is defined as an individual's place of residence (e.g., apartments and residential homes) rather than special institutions (e.g., hospice, long-term care facilities, and nursing homes).

How the intervention might work

Home-based child neglect prevention programs vary from country to country or from organization to organization (Ash, 2017; CDC, 2016; Curry, 2018; Guastaferro, 2022; HHS, 2018; UNICEF, 2023; Van, 2020). We will focus on all formal home-based programs that provided support to families or individuals via the following groups (Donisch, 2022; HHS, 2020):

Engagement of Family

The intervention begins with engagement and trust building. The family will be helped to meet their own goals and their concerns are closely listened.

Why it is important to do this review

As one of the most common types of child maltreatment, studies related to child neglect primarily focus on issues related to child maltreatment. Despite identifying potential interventions in these studies, there is a notable lack of dedicated descriptions for the population experiencing child neglect. Additionally, existing research indicates that current interventions mainly aim to reduce the recurrence of child maltreatment rather than preventing its initial occurrence. Further research is needed to investigate the effectiveness of family interventions and various associated factors in preventing child maltreatment. For instance, Mikton (2009) found that evidence for the effectiveness of four (home-visiting, parent education, abusive head trauma prevention and multi-component interventions) of the seven main types of interventions for preventing child maltreatment is promising. However, concerning home-visiting, some studies included in the analysis consider the evidence inconclusive due to methodological issues, including surveillance bias. Euser (2015) synthesized findings from 27 independent samples from randomized controlled trials (RCTs) on the effectiveness of 20 different intervention programs aimed at preventing child maltreatment, and found currently existing programs appeared to only reduce and not prevent child maltreatment. Further moderator analyses revealed substantial variations in combined effects among different subsets of studies. Specifically, interventions with a moderate number of sessions (16–30) proved significantly more effective than those with fewer or more sessions. Significant effect sizes were observed only for interventions lasting 6–12 months, whereas interventions shorter than 6 months or longer than 12 months did not significantly reduce child maltreatment. The influence on various countries remains uncertain, and the type of sample emerged as a significant moderator affecting the overall effect size. Filene (2013); Segal (2012); Van der Put (2018) summarized findings on effects of interventions (including home visiting program) for preventing child maltreatment and by examining potential moderators and theory of this effect. Han (2022) investigated the effectiveness of home visiting programs targeting parents who have maltreated their children on the prevention of child maltreatment recurrence, the results showed that the risk of child maltreatment recurrence significantly decreased after a home visiting program was implemented.

In addition, some studies have assessed the evidence of only home-based interventions for preventing and reducing child neglect. Further to the best of our knowledge, published systematic reviews of child neglect focused only on the discussion of disease risk factors and adverse consequences of child neglect, incidence and treatment of child neglect, description of evidence for child neglect home visiting programs, and effect of a specific family prevention model. At present, no systematic reviews have evaluated the effect of different home-based intervention models to prevent child neglect. Mulder et al. found 24 potential risk domains of child neglect (Mulder, 2018), and Haslam and Taylor who reviewed the literature exploring the relationship between neglect and adolescent interpersonal functioning in peer relationships found that neglect, particularly emotional neglect, is associated with reduced relationship quality and that there is consistent evidence that neglect increases the risk of gang involvement and deviant peer affiliation (Haslam, 2022). An article (Stoltenborgh, 2013) published in 2013 performed a meta-analysis of the prevalence of physical and emotional neglect but failed to evaluate the effectiveness of interventions for child neglect and the specific content of these interventions. Allin et al. identified 14 studies published from 1985 to 2002 and evaluated the available evidence regarding the effectiveness of child neglect treatment programs (Allin, 2005). Peacock et al. systematically reviewed the effectiveness of home-visiting programs on the developmental and health outcomes of young children belonging to disadvantaged families, including studies that assessed child abuse and neglect (Peacock, 2013). In 2018, the USPSTF reviewed evidence that included home visitation-based prevention interventions to prevent child maltreatment. Although insufficient evidence was found to assess the benefits and harms of preventing maltreatment among children without the signs or symptoms of maltreatment, this recommendation did not assess the effectiveness of home visitation programs for other outcomes (e.g., improving child and maternal health, encouraging positive parenting, or promoting child development) (Curry, 2018; Viswanathan, 2018). Bilukha et al. assessed the effectiveness of home-visiting programs in preventing violence (Bilukha, 2005), whereas McGinn et al. assessed the effectiveness of the formal use of family group decision-making regarding child safety, permanence, child and family well-being, and client satisfaction with the decision-making process (McGinn, 2020). In addition, some reviews integrated the evidence of the effectiveness of other behavioral interventions (such as family group decision-making and those implemented in schools or healthcare facilities) to reduce and prevent child neglect and related health outcomes (McGinn, 2020; Shelley, 2013; Yildiz, 2018).

Criteria for considering studies for this review

Search methods for identification of studies

According to the Campbell Searching for Studies Guide (Kugley, 2016), the pilot searches have been conducted, we will conduct a systematic search of all retrievable studies and reports, as well as hand-search journals to determine the best available evidence. We will complement our searches using Google and Google Scholar to facilitate access to technical reports or governmental publications. Additionally, we plan to conduct forward citation searching with Google Scholar to identify studies citing our included studies. Furthermore, we will perform backward citation searching for references cited in both primary studies and reviews related to the topic identified during our current search. Simultaneously, the search strategy will be determined based on the listed search terms, with no restrictions on date, language, or location.

Data collection and analysis

Selection of studies

Two authors will independently perform a rigorous study screening (Figure 1). The entire screening process will be executed using the EndNote X9 software and Rayyan QCRI. First, duplications will be removed using two software and then the two authors will perform preliminary screening based on the study title and abstract. Second, for the initially included studies, the two authors will rescreen them by searching their full text to determine the final list of studies to be included. During this process, disagreements between the two reviewers, if any, will be resolved by consultation with a third author. At the same time, during the preliminary screening, if there is insufficient information to exclude a study, the study will be further screened using its full text.

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Figure 1

Screening tool.